Robillard, Larry NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Larry J Robillard Male
r Date of Death Age If Veteran of U.S. Armed Forces,
rr April 18, 2016 74 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 8 Second Street
ii Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
;I: John P. Stoutenburg Dr.
?' Address
Glens Falls Hosp,Glens Falls,NY 12801
M Death Certificate Filed District Number Register Number
. City, Town or Village B 60 ) 2 15
❑Burial Date Cemetery or Crematory
April 25, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
}' Hold
N
0 Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
;r r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
: Address
f;: 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
X•:;: Remains are Shipped, If Other than Above
t
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
:r; Date Issued J f b Registrar of Vital Statistics �/C�t.�.�, .� l�J ^1 Na(sig ture)
NA
;:1 District Number rj llL , Place G Cuv- \`S N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition Lo va, Place of Disposition g t..J .i tni-"++€{i.
W (address)
U)
0 (section) _ (lot number) (grave number)
pName of Sexton or Person in Charge of Premises At SQL
Z ' (please print)
W Signature /1 Title /jfeifl1bi2-
(over)
DOH-1555(02/2004)